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How to avoid central venous lines complications
 

How to avoid central venous lines complications

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Presentation by Dr.Hussein Sabri at Emergency Medicine Update Course, the leading emergency medicine event in Egypt. www.emegypt.org

Presentation by Dr.Hussein Sabri at Emergency Medicine Update Course, the leading emergency medicine event in Egypt. www.emegypt.org

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    How to avoid central venous lines complications How to avoid central venous lines complications Presentation Transcript

    • How to Avoid“Central VenousCath.” ComplicationsDr. HusseinSabriHeadof the ScientificCommitteeof EmergencyMedicineEgyptianfellowshipProgram
    • Objectives: Proper patient Assessments & Preparation Proper Equipments Selection & Preparation Tips about Technique & Operative handling Ultra sound use Know When to Stop Post procedure Instructions Diagnosis& Management of Complications
    • Introduction:CentralVenous Catheterizationis Indicated in certainpatients as an urgent or elective procedure Monitoringthe CVP For fluids / blood infusion when indicated to resuscitateHypovolemic & Shocked patients TPN when indicated
    • Introduction:cont.Complicationsaccount to ~ 15-20 % - mostly as :# Infection# Due to Placement / Mechanical difficulties# Thrombosis These Complications could be minimizedmostly by:1 ] Adequate Training 2] The use of Ultrasound &3] Following the Infection ControlGuidelines & use ofAntibioticImpregnated Catheters
    • Placement& Mechanical ComplicationsThese include ; Procedure failure Patient dissatisfaction & discomfort Equipment failure Pneumothorax/ Hemothorax /Chylothorax Hematoma & local soft tissue injury Arrhythmia & Catheter migration
    • ProperPatientAssessment: Patient’s visit: Auditing & consent Revise indications for CV line insertion History : Cardiovascular/ respiratory / Psychic/ coagulation profile / other comorbidities Age: Elder / Children Examination: a) locally- infectionb) Obesity – short neck Ability to lye supine NPO,
    • ProperCatheter Selection: In view of the properly indicated catheter( Tripple lumen CVP cath., Portcath, Mahoker,Permicath., . . . . . . . ) Indicated for medications, TPN, Chemotherapy,.. For short / long term use For High/low flow & viscosity infusions Ease of insertion & removal Familiarity, expiry, tested integrity
    • ProperEquipmentsSelection& Preparation Operating table For easy diff. positioning &weight bearing Monitoring: basic at least GA facility if needed ( medications/equipment ) Resuscitation equipments Ultrasoundmachine
    • PatientsVisit : Assessment, Auditing, Consent, Plan making Preparation and sedation when needed Pre operative medications when indicated( stop Clexan at .... ) Pre operative preparations when indicated(, prepare platelets, FFP, . . . . )
    • C.V. Cath. complicationsIntroduction
    • OperativeManagement ( A ) : Seek Assistant. Revise setup & equipments Follow proper infection control guidelines Position patient on table – ready for slight headdown at time to fill the veins Sterilize site selected according to your plan Oxygen by mask / nasal cannula Sedation / local anesthesia
    • OperativeManagement ( B ) : Prepare US machine – use the HF probe Identify artery & vein Insert your needle, then the guide wire Observe your monitor for arrhythmia Fixation to skin Dressing Record operative data and post op. instructions
    • Ultrasounduse for VascularAccess:Benefits of Ultrasound:• Visualize and localize vascular structures• Provides real-time guidance• Improves accuracy• Shortens procedure time• Improved patient satisfaction• The use of ultrasound decreases complication rates inc:PneumothoraxCarotid/femoral arterial punctureNeedle stick attempts
    • Ultrasoundusefor VascularAccess:National Institute for Clinical Excellence (NICE)• 20 randomized clinical trials• Failed catheter placement risk was reduced by 86%• Associated complications reduced by 57%• First attempt success increased by 41%
    • Ultrasoundusefor VascularAccess:“The use of 2D imaging ultrasoundguidance should be considered in mostclinical circumstances where CVCinsertion is necessary either electively or inan emergency situation.”National Institute for Clinical Excellence
    • Ultrasoundusefor VascularAccess:National Institute for Clinical Excellence (NICE)• 20 randomized clinical trials• Failed catheter placement risk was reduced by86%• Associated complications reduced by 57%• First attempt success increased by 41%
    • Thank YouUltrasoundusefor VascularAccess:
    • Thank YouUltrasound use for Vascular Access:
    • Thank YouUltrasound use for Vascular Access:
    • Thank YouUltrasound use for Vascular Access:
    • STOPwhen you have to STOP ! ! Repeated unsuccessful traumatic trials Majorvascular injury/ technical difficulty Critically ill patient is deteriorating Obese, child, with coagulation defect, .. .. .. .. The need for more senior help The bad need for a piece of equipment, spare On patient’s request
    • PostOperative Care - Guidelines Test your line for a free back flow Request CXR Strict A septic handling &nursing care Antibiotic cover !! Our major enemies are infection / obstruction Hep. Sal. Flushing& Heparin lock( > 24 h ) Opening the catheter only in the supineposition
    •  Relatedto violationof InfectionControlpolicies Infectionat exit site , followedby migrationoforganismson externalsurface, endsinintraluminarcatheter colonizationandthrombusformationInfectious Complications :
    • AntimicrobialImpregnatedCatheters: ImpregnatedwithChlorhexidine&SilverSulfadiazine OR ImpregnatedwithMinocycline& Refampin Reporteddecreasein the rateof Catheterrelatedbloodstreaminfection Resistantorganismcoulddevelop
    •  Int. JagularCath. Can be difficultin themorbidlyobesepatients Subclavianvein Cath.Shouldbe avoidedin severelyhypoxicpatients( higher riskof Pneumothorax) Femoralvein Cath.Is easyand quick fortreatmentof shockApproach Related Complications
    • Thrombotic Complications Femoral 20 times > Subclavian 33 % in ICU All thromboseshave the potentialto embolize ProphylacticAntiplatelets/ Anticoagulantisadvisedin the vulnerable& hypercoagulablept.
    • Diagnosisof Complications: Clinicaldata ( symptoms & signs ) Diagnostic Lab. Work ( CBC, Blood culture, .. ) Diagnostic Radiology ( XR, CT, MRI, . . .)
    • Managementof Complications:Medical / Surgical line of management i.e. Blood culture , Antibiotics Removalof the catheter Blood transfusion,. . Chest tube insertion Specific surgical intervention,, . . . Other lines of treatment as indicated ………
    •  Preprocedurepreparations& planof action(Failingto planis planningto fail) Tipstothe operatorto maximizesuccessrates Ultrasoundusein vascularaccess Benefitsand valueof US toreducecomplications Applicationof InfectionControlPolicies Valueof postprocedureinstructions Earlydiagnosis& managementof complicationsSummary:
    • Thank You